Friday, April 16, 2010

Think Again

In the throwaway journal Current Psychiatry, editor Henry Nasrallah, M.D. offers what he calls a "psychiatric manifesto," a professional apologia of a kind, which is an interesting if typical example of the perennially insecure status of the discipline.

Here is an alternative "manifesto:"

1. Psychiatry deals with diverse impairments of mood, behavior, motivation, cognition, relatedness, self-understanding, impulse control and personal integration; that is, it deals with disorders of the self. While other areas of medicine deal with generic aspects of biological functioning, psychiatry specifically concerns itself with obstructions to self-determined individuality, in other words, selfhood.

2. Self-determined individuality has an essentially narrative aspect; the self comprises self-fulfilling stories which coincide or clash with the self-fulfilling stories of other persons. That is why third-party corroboration ("collateral information") is so often crucial to psychiatric assessment, and why psychiatry is irreducibly linguistic and why it has so little to say about an unconscious patient.

3. All mental phenomena derive from brain phenomena, so in principle all subjective experience may be influenced by neurophysiological means. However, as noted above, neurology deals with the generic aspects of brain functioning (its infrastructure as it were), whereas psychiatry deals with the idiosyncratic story that the brain, impinged upon by surrounding stories, endeavors to tell about itself. Mental disorders therefore entail an unstable and not precisely definable mixture of voluntariness and involuntariness.

4. While brain phenomena underlie all mental phenomena, the current very limited state of neuroscientific insight is such that practicing psychiatrists are not neuroscientists any more than, say, taxi drivers are auto mechanics. For the routine practice of contemporary psychiatry, the vast majority of neuroscience per se is irrelevant. This may change in the future, but despite freqent promises over the past twenty years that this will change any day now, it hasn't yet.

5. Because it aspires to authority over potentially controversial and debatable aspects of human conduct, such as matters of human behavior, identity, and relatedness, psychiatry has an inherently political and contentious dimension. Psychiatric nosology is an ongoing global process of consensual negotiation in which psychiatrists, while experts of a kind, are also mere participants.

6. Increasing knowledge of brain science and technology will no more solve disputes over psychiatric diagnosis than, say, the Internet has solved political problems. Debates over, say, psychotherapy versus medication arise to some degree from contrasting sensibilities and climates of opinion and are not therefore altogether resolvable by evidence-based analyses.

7. For the above reasons, while the stigma of mental disorders is very often damaging and regrettable, it is naive to think that such ailments will ever be as simple or as straightforward as many medical problems. This is so because any diagnosis constitutes not merely description, but also a moral claim, and in psychiatry's case, an unavoidably equivocal one.

8. While psychiatry as a discipline is probably no more flawed than any other large human institution dealing with complex phenomena, it is unhelpful to view critics of psychiatry as necessarily "ignorant" or "self-interested." The controversy has to do not with any exceptional benightedness of the discipline or its detractors, but rather is inseparable from the nature of the undertaking. Psychiatry attracts critics for the same reason that, on larger scales, the federal government or the Catholic Church do: all relate to powerful and yet deeply ambiguous human needs and vulnerabilities.

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